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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430757125
Report Date: 03/29/2023
Date Signed: 04/04/2023 09:46:13 AM


Document Has Been Signed on 04/04/2023 09:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:CRUZ, GUADALUPEFACILITY NUMBER:
430757125
ADMINISTRATOR:CRUZ, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 225-2941
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:14CENSUS: 3DATE:
03/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Guadalupe CruzTIME COMPLETED:
12:35 PM
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Licensing Program Analysts (LPA), Farida Raja and Joseph Macias, conducted an unannounced 1- year annual inspection. LPAs were granted access to the home by Licensee, Guadalupe Cruz, and explained the nature of today’s inspection. LPAs observed 3 adults- Licensee, Daughter/staff, Sarai Cruz and Licensee's sister- Lucia Mendoza working as volunteer) and 3 children( 2 infants, 1 preschool) in the home during today’s inspection. One school age child arrived at 11:45am and another infant at 12:08pm. Licensee was operating within the ratio and capacity requirements of her license. Days and hours of operation are Monday to Friday 5:00 AM to 6:00 PM. The kitchen area is currently under construction and Licensing was informed of this on 12/30/2022. LPAs observed all required posted materials near the front entrance to the home. The adults that reside in the home are licensee and spouse (Beltran Cruz).

LPAs toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home (408-225-2941, cell phone 408-250-4075). LPAs observed sufficient materials, toys, and play equipment for the day care children. Furniture, such as tables, chairs, cribs and shelves, are in good condition. The home has central heating/cooling and ventilation for comfort of children. The home is single story and LPAs observed no stairs in the inspected areas. Off limit areas inside the home: master bedroom, 2 bedrooms, attached garage and additional add-on room used as storage. LPAs observed a barricaded fireplace in the on limits family room area. Off limit areas outside the home: entire backyard. There are no bodies of water in the backyard. LPAs observed that the bathroom used by children was in operating condition. Toilets and faucet are clean and operable. The shower area is free on any hazards.

LPAs observed a fully charged 3A40BC fire extinguisher in the kitchen area and working smoke/carbon monoxide detector. The Licensee states that she does not have any weapons or pets in the home. All hazardous products are stored inaccessible to children. Licensee understands that smoking is prohibited in the home.

Drinking water is readily available for children in the home via individual water bottles/bottled water. Licensee states that she provides meals and snacks to the children in care. Licensee understands that any
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida RajaTELEPHONE: (916) 566-5850
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CRUZ, GUADALUPE
FACILITY NUMBER: 430757125
VISIT DATE: 03/29/2023
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food brought from home shall be labeled with each child's name and properly stored or refrigerated.

LPAs reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. Fire/disaster drill was last documented on 02/17/2023. LPAs obtained a copy of children's roster. Three (3) children’s files were reviewed during today's inspection and found to have some required documents missing. Licensee carries daycare insurance. Licensee states that she has liability insurance through DCI Insurance and LPAs observed a current policy verifying valid coverage.

LPAs discussed the safe sleep regulations with Licensee, including documentation that shall be maintained and conducting 15-minute checks on all sleeping infants. LPAs discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPAs did not observe a record of 15-minute check conducted and reminded licensee to conduct and document these checks on all infants under 2 years of age.

A review of staff records during today's inspection indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Staff file review was completed and found to be current and up to date. Licensee has current Pediatric CPR/First Aid certification with an expiration date of 07/30/2024. Licensee and staff have the required vaccines (MMR, Tdap, & statement declining influenza) and are current with Mandated Reporter Training for Child Care Workers. Licensee's Mandated Reporter Training expires on 09/19/2024.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12-month period.

Supervision of children was discussed with Licensee, and she understands that she or a qualified adult must be present in the home during day care hours and ensure that the children are supervised at all times.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida RajaTELEPHONE: (916) 566-5850
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CRUZ, GUADALUPE
FACILITY NUMBER: 430757125
VISIT DATE: 03/29/2023
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The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time and a qualified assistant must be present. Licensee understands in absence of a helper her license capacity is reduced to 8 and ratio (age of the children) must be observed.
LPAs discussed "zero tolerance" related regulations and advised that the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation.

Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov/ www.ccld.ca.gov to access resources for providers, regulations, adoptions of new laws, pay annual fees etc.

Licensee states that a child will be isolated in the living room if necessary due to illness or communicable disease. Licensee states that she does not administer any medications to the day care children currently. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding Americans with Disabilities Act (ADA) was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

The Licensee states that she does not transport any day care children. LPA reminded Licensee that if she decides to transport children, children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.



To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dess.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Two (2)Type B deficiencies were cited today. Appeal rights were printed and given to Licensee. Exit interview was conducted with licensee, Guadalupe Cruz.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida RajaTELEPHONE: (916) 566-5850
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/04/2023 09:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: CRUZ, GUADALUPE
FACILITY NUMBER: 430757125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above for the three infants in care. Licensee stated that she observes the infants sleeping, but has not documented the 15 minute checks, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2023
Plan of Correction
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Licensee stated that she will implement a 15 minute check for all sleeping infants up to age 2 and send a copy to CCL by the POC date of 04/12/2023.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and record review, the licensee did not comply with the section cited above for Child #1 and #2 which poses a potential health, safety or personal rights risk to persons in care. Licensee stated that Child # 1 has not received his vaccinations because of
POC Due Date: 04/12/2023
Plan of Correction
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Licensee will submit all missing paperwork for Child #1 and #2 by the POC of 04/12/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida RajaTELEPHONE: (916) 566-5850
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4